| NPI | 1184377731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5354) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11771) |
| Enumeration Date | 2022-02-02 |
| Last Update Date | 2025-04-29 |